The role of the built environment has received growing attention in relation to its contribution to diet and health outcomes such as obesity( Reference Lake and Townshend 1 ). Food and nutrition environments have been transforming rapidly over the past few decades( Reference Story, Kaphingst and Robinson-O’Brien 2 ), with many changes in access and availability of foods in line with shifting patterns of dietary intake( Reference Popkin, Duffey and Gordon-Larsen 3 ) and social demographics( Reference Hayes 4 ). Decreased availability of and accessibility to supermarkets has been identified as a key barrier to consuming a healthy diet( Reference Bodor, Rose and Farley 5 ) and a number of studies have reported on healthier food options being more expensive than less healthy foods( Reference Jetter and Cassady 6 ). In environments that are seemingly less supportive of healthy eating, it is often difficult to make nutritious food choices when reduced availability, accessibility and affordability challenge the ability to acquire healthier alternatives( Reference Osei-Assibey, Dick and Macdiarmid 7 ).
The local food environment has usually been categorised and measured in terms of different types of food outlet including the supermarkets, corner stores, fast-food outlets and restaurants available to individuals where they live( Reference Holsten 8 ). Based on this work, Glanz and colleagues( Reference Glanz, Sallis and Saelens 9 ) have developed a conceptual framework that identifies three types of environments including the community nutrition environment (types of stores, accessibility), the consumer (within-store) nutrition environment (availability of healthy options, price, nutrition information) and the organisational nutrition environment (home, school or work). These environments are influenced by a combination of government and industry policies and the information environment (media and advertising), which work in combination with individual factors such as sociodemographic characteristics, psychosocial factors and the perceived nutrition environment and ultimately help determine eating patterns and behaviour( Reference Glanz, Sallis and Saelens 9 ).
Much of the existing quantitative literature has sought to establish a relationship between the food environment (particularly the community nutrition environment) and both dietary behaviours and/or weight status( Reference Osei-Assibey, Dick and Macdiarmid 7 , Reference Caspi, Sorensen and Subramanian 10 ). However, results have been inconsistent and the role of the food environment on eating patterns is far from understood( Reference Glanz, Sallis and Saelens 9 ). While most evidence on the links between the food environment and dietary intake comes from quantitative studies, as demonstrated by a series of systematic reviews( Reference Osei-Assibey, Dick and Macdiarmid 7 , Reference Glanz, Sallis and Saelens 9 – Reference Engler-Stringer, Le and Gerrard 13 ), far less research has been undertaken in terms of understanding the food environment from a qualitative perspective.
There is no currently published systematic review of qualitative literature that has specifically looked at the local food environment and dietary behaviours. Much of the qualitative research has explored socio-ecological determinants of food choices and/or dietary behaviours of different population groups (children( Reference Holsten 8 , Reference Williams, Veitch and Ball 14 ), adolescents( Reference Christiansen, Qureshi and Schaible 15 , Reference Watts, Lovato and Barr 16 ) and socio-economically disadvantaged populations( Reference Inglis, Ball and Crawford 17 , Reference Williams, Ball and Crawford 18 )) in a range of environments (home( Reference Holsten 8 , Reference Watts, Lovato and Barr 16 ), school( Reference Nollen, Befort and Snow 19 , Reference Watts, Lovato and Barr 20 ) or local community( Reference Engler-Stringer, Le and Gerrard 13 , Reference Inglis, Ball and Crawford 21 )). Although one qualitative systematic review has explored obesogenic dietary intake in young children( Reference Mazarello Paes, Ong and Lakshman 22 ) and another has focused on determinants of fruit and vegetable consumption in children and adolescents( Reference Krolner, Rasmussen and Brug 23 ), neither solely considered environmental determinants or food and purchasing behaviours.
Given the difficulty of studies and systematic reviews of quantitative literature in establishing associations between objective measures of the food environment and dietary behaviours or health outcomes such as obesity, the current review aims to investigate what the qualitative literature tells us about the influence of the local food environment on food and purchasing behaviours. Synthesising qualitative evidence will enable an in-depth exploration of food environments to provide greater understanding of possible explanations for contrary outcomes, assist to inform and generate new hypotheses in quantitative research and subsequently guide the design of public health policy, interventions and practice( Reference Dixon-Woods, Bonas and Booth 24 ).
Methods
The current review adheres to the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) statement to ensure quality of methods and reporting( Reference Moher, Liberati and Tetzlaff 25 ).
Search methods
Six electronic databases were searched using keyword searches of entire articles. The databases included MEDLINE, Health Reference Centre, CINAHL Plus with full text, PsycINFO, PubMed and Australian and New Zealand Reference Centre. Terms were selected to define essential elements of the search including the environment and specifically the type of environment, food and dietary intake, qualitative research methods, as well as key food environment concepts. A list of search terms and lateral searching methods are provided in the online supplementary material, Supplemental Tables 1 and 2.
Eligibility criteria
Articles were included if they incorporated a qualitative research method with the inclusion of participant comments or quotes; were a primary study published in a peer-reviewed academic journal between 2000 and 2015; and were written in English language. The inclusion of the 15-year time period was selected given the increasing contribution to the food environment literature during this time( Reference Engler-Stringer, Le and Gerrard 13 , Reference Lytle 26 ).
The current review was particularly interested in explicit references made to people’s food consumption and/or purchasing behaviours or related environmental determinants as a function of the local food environment, as supported by specific quotes from participants. Research focusing on dietary intakes of specific micro- or macronutrients or particular health or nutrition conditions/disorders, as well as studies on dietary acculturation or food security outside the context of food environments and purchasing behaviours, were excluded.
Some criteria were further refined such as excluding articles based on their setting, specifically schools, workplaces and within-home environments, due to the additional scope and diversity afforded by these other types of food environments. Additional eligibility criteria were defined during the study selection process including the decision to include articles sampling adults and/or children within urban/metropolitan areas, but only if reported from the perspective of an adult, as the primary purchaser of food. Rural localities, as defined by the paper in their original context, were excluded given the potential differences in food environments between rural and urban areas.
Study selection
Articles identified through database searches were imported into EndNote version X7. Duplicate records, non-English language articles and non-journal articles were removed. One author (E.P.) reviewed titles, abstracts and identified articles required for full-text evaluation. Inclusion or exclusion of full-text articles was undertaken independently by three authors (E.P., D.G. and L.T.) and then determined by majority consensus upon group discussion. Additional articles were retrieved from reference lists of included articles. The PRISMA flow diagram is recommended to document the systematic review search and selection process( Reference Tong, Flemming and McInnes 27 ) and its application to the current review can be seen in Fig. 1.
PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) flow diagram of the search and screening process for the current systematic review
Quality assessment
Although there is currently a lack of consensus regarding the best tool for undertaking quality assessment of qualitative research( Reference Dixon-Woods, Shaw and Agarwal 28 ), the Critical Appraisal Skills Programme (CASP) tool for appraising qualitative research is one recognised appraisal tool and was subsequently used to undertake quality assessment of studies included in the current review( 29 ). The purpose of the quality assessment was not to exclude articles based on their quality but simply to assess their rigour, credibility and relevance( Reference McInnes and Chambers 30 ). This assisted in gaining a depth of understanding of the articles included( Reference Ring, Ritchie and Mandava 31 ), particularly in terms of their strengths, weaknesses and overall contribution to the review( 32 ).
Data extraction and analysis
Summary data of eligible studies were extracted including authors and year of publication; study location; study aim; sample characteristics; and data collection methods.
Data analysis utilised the thematic synthesis process as detailed by Thomas and Harden( Reference Thomas and Harden 33 ), which is a widely used approach to analysing and synthesising qualitative data within systematic reviews( Reference Ring, Ritchie and Mandava 31 ). The three main stages of this method included inductive line-by-line coding of article findings; developing descriptive codes to translate concepts between studies; and finally developing analytic codes to transform findings beyond the context of the original studies to generate new meaning and understanding. All major sections of empirical findings focusing on the local food environment and food/purchasing behaviours or related environmental determinants were free coded (E.P.) for four articles and then cross-checked (D.G.) for quality assurance and consensus. The remaining articles were subsequently coded in the same manner.
Descriptive themes were developed by grouping individual codes by topic or similar ideas. Codes were then reorganised into a hierarchal structure under themes, allowing individual codes to sit under multiple descriptive themes or left in free code form. Descriptive themes and codes were iteratively reorganised and refined with similar or overlapping codes and themes being merged together. All authors participated in ongoing critical discussion regarding refinement of codes and themes.
Analytic themes emerged through an iterative inductive and deductive approach. First, the relationships between descriptive themes were examined and then applied to answer the review question. The latter evolved by conceptualising the relationship between the food environment and dietary intake, as presented through initial coding and generation of descriptive themes. Similarities emerged with Glanz and colleagues’ model of nutrition environments( Reference Glanz, Sallis and Saelens 9 ) and thus their framework was used deductively to structure the findings in the context of existing literature and current understanding of food environments. Final descriptive themes and codes became mutually exclusive under analytic themes.
Results
Summary of included studies
A total of 2744 articles were identified through the search process, of which thirty met the inclusion criteria for the review (Fig. 1). Included studies were published between 2001 and 2015, with nineteen from the USA, seven from the UK and one each from Mexico, Canada, Australia and the Netherlands. Data collection methods included focus groups (n 14), interviews (n 12) and a combination of interviews and focus groups (n 4). Sixteen articles sampled participants specifically for characteristics of socio-economic position and seventeen articles sampled participants either solely or predominantly from ethnically diverse communities, thirteen of which consisted of African-American populations. A summary of the included studies can be seen in Table 1.
Summary characteristics of studies included in the current systematic review
SES, socio-economic status.
Information in the above table represents information/participants that met the inclusion criteria. For example, if a study used a mixed-methods research design, details are not provided on the number of survey participants in the study or if the study incorporated both rural and metropolitan areas, details on the rural participants (if made explicit) have not been provided.
* Number of rural participants cannot explicitly be identified and excluded from the sample.
† Number of females and males not identified.
Quality assessment
The outcomes from the quality assessment are presented in the online supplementary material, Supplemental Table 3. Only four of the thirty articles met the criteria for all domains of quality. All articles provided a clear statement of aims, qualitative methodology and research design; however, two lacked key details regarding their recruitment strategy, five did not provide information on ethical clearance and twelve did not consider the relationship between researchers and participants during research design or data collection. There was no mention or detail provided regarding data saturation as part of data analysis in twenty-three of the articles, seven did not consider implications of bias either during analysis or reporting, and two articles failed to discuss the credibility of their research findings. Finally, three articles did not consider applicability or transferability of the research.
Key findings
Thematic synthesis results are presented under four key analytic themes: (i) the community nutrition environment; (ii) the consumer nutrition environment; (iii) other environmental factors; and (iv) individual coping strategies for shopping and purchasing decisions. A matrix of key themes identified across the included studies can be seen in Table 2. The analytic themes represent a blend of concepts that either directly or partially align with Glanz and colleagues’ model of nutrition environments( Reference Glanz, Sallis and Saelens 9 ) and provide a means of understanding the findings in terms of current food environment literature.Footnote * However, the themes also highlight other novel and emergent ideas. For example, behaviours such as coping strategies are not represented within this particular framework.
Summary of analytic and key descriptive themes across studies included in the current systematic review
Y, yes; –, not applicable.
* Socio-economic factors not considered or discussed within articles (n 3).
† Racial or culturally diverse factors discussed within articles and pertaining to key themes (n 8).
Theme 1: Community nutrition environment
Availability
The comparative availability of healthy and unhealthy options in the food environment was identified as playing a key role in food purchasing decisions and was discussed by sixteen articles included in the present the review from predominantly lower-income or minority populations in the Netherlands, Australia, USA and UK. Articles mentioned the proliferation of takeaway foods within communities( Reference Inglis, Ball and Crawford 17 , Reference Rawlins, Baker and Maynard 34 ) and decreased or declining availability of produce, which was seen as one of the biggest influences on diet( Reference Lucan, Barg and Karasz 35 ). Concern was raised regarding the availability of convenience or junk foods within stores( Reference Rawlins, Baker and Maynard 34 ), the proximity to fast food, and thus the subsequent increased consumption of these foods( Reference James 36 – Reference Yen, Scherzer and Cubbin 39 ) and decreased consumption of fresh produce( Reference Kamphuis, van Lenthe and Giskes 40 ):
‘every corner sells fast food … [so it’s] hard not to buy it.’ (Lucan et al.( Reference Lucan, Barg and Karasz 35 ), p. 705)
Articles mentioned greengrocers( Reference Kamphuis, van Lenthe and Giskes 40 ) and other stores either closing down or moving out of the area due to lack of trade( Reference Piacentini, Hibbert and Al-Dajani 41 ) or overwhelming competition( Reference Kamphuis, van Lenthe and Giskes 40 ). Reference was also made to the lack of larger, high-quality supermarkets within neighbourhoods, forcing consumers to shop outside their local area( Reference Munoz-Plaza, Filomena and Morland 42 ).
Culturally and linguistically diverse populations located in both the USA and the UK referred to the difficulties in obtaining traditional foods due to limited availability( Reference Rawlins, Baker and Maynard 34 ). Consumers would often choose to frequent particular stores because of cultural availability and variety of ethnic foods( Reference Webber, Sobal and Dollahite 43 ), yet rejected stores that sold unfamiliar items or those catering for other ethnic groups( Reference Cannuscio, Hillier and Karpyn 44 ).
One US-based article identified the phenomenon of local food environments being both ‘raced’ and ‘classed’, with a clear segregation of food stores being a result of racism and oppression( Reference Freedman 45 ). Minority communities such as African-American communities were often in areas with little or no availability of healthy foods( Reference Freedman 45 ). Subsequently it was identified that ‘white’ areas often had better availability, as well as variety and quality of foods( Reference Zenk, Odoms-Young and Dallas 46 ), with good food stores generally perceived to be in better areas of town( Reference Freedman 45 , Reference Kumar, Quinn and Kriska 47 ). Marked differences were seen in both the availability and quality of foods sold in predominantly African-American areas( Reference Rose 48 ) or low-income communities, including populations from the Netherlands and Australia( Reference Inglis, Ball and Crawford 17 , Reference Kamphuis, van Lenthe and Giskes 40 ), compared with those in white and more privileged areas( Reference Freedman 45 ) and thus food quality was also a function of store clientele( Reference Kumar, Quinn and Kriska 47 ):
‘Same price. Low quality … food is directed to the area.’ (Kumar et al.( Reference Kumar, Quinn and Kriska 47 ), p. 374)
Equity issues were also identified solely in US populations through chain stores stocking different products depending on the neighbourhood( Reference Freedman 45 ), thus potentially highlighting inequitable access to food choices( Reference Zenk, Odoms-Young and Dallas 46 ). Local food environments tended to mirror the social class of the community and consumers endeavoured to shop at stores congruent with their social status, clearly highlighting class differences in where people shop( Reference Cannuscio, Hillier and Karpyn 44 ).
Accessibility
Accessibility was identified as a key determinant of food purchasing behaviours in terms of where food stores were located as well as transport options that facilitate access and was discussed in eighteen articles from the USA, the UK and Australia, being particularly evident for lower socio-economic groups. A number of barriers to accessing local stores were identified( Reference Inglis, Ball and Crawford 17 , Reference Freedman 45 ), including having to rely on others for use of private vehicles( Reference Clifton 49 – Reference Dammann and Smith 52 ) or being able to frequent only nearby convenience stores if access to private or public transport was not an option( Reference Piacentini, Hibbert and Al-Dajani 41 , Reference Freedman 45 , Reference Zenk, Odoms-Young and Dallas 46 , Reference Hendrickson, Smith and Eikenberry 53 ):
‘I mean, you’re not fixing to find any foods or anything in the convenience store. It’s a horrible thing, you know, for those who don’t have it [transportation], because they are forced to go to one of those convenience stores … They [the stores] don’t have real food over there.’ (Freedman( Reference Freedman 45 ), p. 388)
References were also made to the sporadic availability of jitneys (informal taxi service)( Reference Rose 48 ) at certain local stores, therefore limiting store choice for those reliant, primarily African-American communities, on this form of public transport( Reference Kumar, Quinn and Kriska 47 ).
Given the suboptimal availability of items in local stores, good food stores were often seen as being far away( Reference Freedman 45 ). Afforded the opportunity, preference was given to leaving the local community and travelling further for food to obtain better-quality and variety of foods as well as to save money( Reference Munoz-Plaza, Filomena and Morland 42 , Reference Clifton 49 ) and this was particularly due to dissatisfaction with neighbourhood stores within US-based localities( Reference Rose 48 ).
Walkability was a key priority for low-income and minority population groups within the UK and US populations without access to cars( Reference Piacentini, Hibbert and Al-Dajani 41 , Reference Zenk, Odoms-Young and Dallas 46 , Reference Rose 48 , Reference Clifton 49 , Reference Whelan, Wrigley and Warm 51 , Reference Tach and Amorim 54 ). Articles also made reference to the influence of transportation mode on shopping frequency( Reference Whelan, Wrigley and Warm 51 , Reference Dammann and Smith 52 ). Access to private motor vehicles usually meant less frequent shopping trips compared with more frequent trips made by those who walked or used public transport( Reference Rose 48 ), the latter of whom also needed to factor in the cost of each trip( Reference Piacentini, Hibbert and Al-Dajani 41 , Reference Munoz-Plaza, Filomena and Morland 42 ). Public transport was also seen as impractical and difficult when required to transport heavy groceries home, especially fruit and vegetables, or to shop with young children( Reference Piacentini, Hibbert and Al-Dajani 41 , Reference Clifton 49 , Reference Lawrence, Skinner and Haslam 50 , Reference Dammann and Smith 52 ). Thus location of and access to stores was a key determinant to buying and consuming fresh produce( Reference Lucan, Barg and Karasz 35 , Reference Lawrence, Skinner and Haslam 50 ).
Affordability
Twelve primarily US-based articles referred to distinct differences in price depending on the type of store. Corner stores( Reference Piacentini, Hibbert and Al-Dajani 41 , Reference Munoz-Plaza, Filomena and Morland 42 , Reference Rose 48 , Reference Dammann and Smith 52 , Reference Hendrickson, Smith and Eikenberry 53 , Reference Tach and Amorim 54 ) and meat markets( Reference Zenk, Odoms-Young and Dallas 46 , Reference Dammann and Smith 52 ) were usually said to be much more expensive than supermarkets, chain superstores( Reference Cannuscio, Hillier and Karpyn 44 ) or public markets( Reference Bridle-Fitzpatrick 55 ):
‘Milk is normally 79 pence for the big jugs. I just go down to the [store] and get it there because up here it’s [1 pound]…’ (Piacentini et al.( Reference Piacentini, Hibbert and Al-Dajani 41 ), p. 150)
Consumers often referred to local food stores as overpriced( Reference Webber, Sobal and Dollahite 43 , Reference Freedman 45 , Reference Zenk, Odoms-Young and Dallas 46 , Reference Dammann and Smith 52 , Reference Hendrickson, Smith and Eikenberry 53 ) and taking advantage of local residents( Reference Zenk, Odoms-Young and Dallas 46 , Reference Hendrickson, Smith and Eikenberry 53 ). Specific reference was also made to the same items in different stores being more expensive( Reference Munoz-Plaza, Filomena and Morland 42 ).
Theme 2: Consumer nutrition environment
In-store food availability
In-store availability of fruit, vegetables and meat was reported as a key driver of food store choice( Reference Piacentini, Hibbert and Al-Dajani 41 , Reference Krukowski, McSweeney and Sparks 56 ) and was discussed in fifteen articles from the Netherlands, USA and UK. Contrary to this, however, the availability of fresh produce was often referred to as unreliable and sporadic( Reference James 36 , Reference Freedman 45 ), especially in lower socio-economic areas. Corner stores and mini-markets were described as having less variety( Reference Rose 48 , Reference Hendrickson, Smith and Eikenberry 53 ) and fewer (if any) healthy items or alternatives( Reference Munoz-Plaza, Filomena and Morland 42 , Reference Cannuscio, Hillier and Karpyn 44 – Reference Zenk, Odoms-Young and Dallas 46 , Reference Lindsay, Sussner and Greaney 57 ) than supermarkets( Reference Cannuscio, Hillier and Karpyn 44 , Reference Freedman 45 ). Local food stores tended to be stocked with unhealthy snack foods, cold drinks, cigarettes and beer( Reference Freedman 45 ). Consequently this limited the variety of healthy food people had access to, particularly if they were reliant on corner stores for their food purchasing( Reference Lindsay, Sussner and Greaney 57 ):
‘Far as fruit, there ain’t no fruit there [at the local convenience store]. I don’t remember seeing no kind of, you know, like oranges, bananas, apples, tangerines, peaches; I don’t see none of that down there. They ain’t got no fruits or nothing.’ (Freedman( Reference Freedman 45 ), p. 390)
In-store food quality
Nine articles, predominantly based in the USA, reported on customer concern regarding poor quality and safety of foods they could select from( Reference Piacentini, Hibbert and Al-Dajani 41 , Reference Munoz-Plaza, Filomena and Morland 42 , Reference Rose 48 , Reference Hendrickson, Smith and Eikenberry 53 ). Consumers mentioned displays of withering fruit and vegetables( Reference Webber, Sobal and Dollahite 43 , Reference Freedman 45 , Reference Zenk, Odoms-Young and Dallas 46 , Reference Hendrickson, Smith and Eikenberry 53 ), canned goods and meats close to expiration( Reference Webber, Sobal and Dollahite 43 , Reference Kumar, Quinn and Kriska 47 ), and spoiled or rotting meats( Reference Munoz-Plaza, Filomena and Morland 42 , Reference Zenk, Odoms-Young and Dallas 46 , Reference Rose 48 ). Consumers discussed closely inspecting food prior to purchasing( Reference Webber, Sobal and Dollahite 43 ) but also refusing to purchase fresh produce because of quality( Reference Zachary, Palmer and Beckham 58 ), opting to buy canned produce instead, or purchasing fresh foods from outside the community( Reference Freedman 45 , Reference Zenk, Odoms-Young and Dallas 46 ). Reference was also made to deceptive sales practices utilised by stores to disguise spoiled produce( Reference Munoz-Plaza, Filomena and Morland 42 ), resulting in distrust of local food stores:
‘I just take for granted when I go to the store that it’s going to be fresh, but not around here; here sometimes you have to blow the dust off and check the date.’ (Webber et al.( Reference Webber, Sobal and Dollahite 43 ), p. 300)
Food store characteristics or features
Eight articles (seven from the USA and one from the UK) identified specific features or characteristics of food stores that play a role in influencing a person’s decision to frequent a particular store and make food purchases, including in-store promotions and product placement, as well as cleanliness and customer service. Such factors were mostly referred to in minority or lower socio-economic communities.
In-store promotions and product placement
In-store marketing, promotions and sales were discussed in relation to their influence on promoting purchasing decisions. These promotions were helpful for some who searched for items on sale( Reference Tach and Amorim 54 ), while others perceived them to be exploitive and complicated( Reference Webber, Sobal and Dollahite 43 ). Specific reference was made to the heavy promotion of junk foods in terms of price, as well as their placement within the store to encourage unhealthy purchases( Reference Zachary, Palmer and Beckham 58 ). Consumers often made comment on displays put at store entrances to catch their attention, ‘wall of values’ and junk foods placed directly in front of healthy items such as fresh produce( Reference Lindsay, Sussner and Greaney 57 ). It was also noted that promotions and sales rarely applied to fresh produce( Reference Webber, Sobal and Dollahite 43 ):
‘It’s all the buy-one-get-one-free on big bars of chocolate and big cakes ... but you never see buy-one-get-one-free by big bags of fruit.’ (Lawrence et al.( Reference Lawrence, Skinner and Haslam 50 ), p. 1008)
Further to marketing and sales often favouring unhealthy foods, a couple of articles discussed the fact that healthier food items were not easily identifiable within store. They mentioned that healthy items were available but difficult to identify( Reference Zachary, Palmer and Beckham 58 ) due to their placement and marketing( Reference Zenk, Odoms-Young and Dallas 46 ). Although some stores had separate sections for their healthy products, there was a general lack of shelf labelling to identify such items, with labels usually used only to highlight product prices and specials( Reference Zachary, Palmer and Beckham 58 ).
Cleanliness
Store cleanliness was reported as an important determinant of store choice( Reference Krukowski, McSweeney and Sparks 56 ). Clean stores were associated with perceptions of fresh and wholesome food( Reference Webber, Sobal and Dollahite 43 ) with customers also associating poor upkeep with poor-quality food( Reference Zenk, Odoms-Young and Dallas 46 ). Consumers discussed refusing to shop in a particular store if the cleanliness did not meet expectations( Reference Freedman 45 , Reference Zenk, Odoms-Young and Dallas 46 ):
‘I walked in the store and it was just like nasty… we’re not fixing to get nothing from up out of here because they’ve got roaches and the floor is filthy dirty. I’m gone.’ (Zenk et al.( Reference Zenk, Odoms-Young and Dallas 46 ), p. 285)
Customer service
Poor attitudes and a lack of courtesy were identified as barriers to food purchasing and patronising certain stores( Reference Munoz-Plaza, Filomena and Morland 42 , Reference Zenk, Odoms-Young and Dallas 46 ). Several articles discussed what patrons look for in terms of good customer service such as staff that are adequately trained( Reference Webber, Sobal and Dollahite 43 , Reference Cannuscio, Hillier and Karpyn 44 ), are helpful to customers in finding particular items( Reference Cannuscio, Hillier and Karpyn 44 , Reference Krukowski, McSweeney and Sparks 56 ) and reasonable management who a receptive to feedback and handling complaints( Reference Webber, Sobal and Dollahite 43 ). Customers looked for welcoming environments where they were greeted upon arrival( Reference Krukowski, McSweeney and Sparks 56 ), made to feel accepted, treated with respect and on a first-name basis with management or employees. Customers expected a degree of service that was in line with the demeanour of the particular store; however, customers reported differing attitudes depending on the store they shopped in( Reference Webber, Sobal and Dollahite 43 ).
Theme 3: Other environmental factors
Influence of media and advertising
Four articles (two from the USA and one each from Canada and the UK) discussed the role of television-based media or outdoor advertising of fast food as influences on people’s food choices. One article attributed the choice of out-of-home eating establishment to advertising and marketing techniques( Reference McGuffin, Price and McCaffrey 37 ). Media was identified as an important influence on diet( Reference Lucan, Barg and Karasz 35 ) and children’s pester power and request for unhealthy foods while grocery shopping was attributed to particular products being seen on television( Reference Dwyer, Needham and Simpson 59 ).
Other environmental factors
Factors broader than the food environment were also identified as having an influence on people’s choice of shopping location such as neighbourhood characteristics and safety concerns, which were identified in four US-based articles. People spoke of being hassled by loiterers in front of food stores( Reference Zenk, Odoms-Young and Dallas 46 ), nearby drug sales or alcohol-related violence( Reference Cannuscio, Hillier and Karpyn 44 ) as well as general safety in grocery store car parks( Reference Krukowski, McSweeney and Sparks 56 ). Personal safety was identified as a determinant of shopping location( Reference Rose 48 ) with people choosing to avoid stores where they had heard of violent incidents occurring( Reference Krukowski, McSweeney and Sparks 56 ):
‘I don’t really like going certain places … cause I just don’t feel safe …’ (Zenk et al.( Reference Zenk, Odoms-Young and Dallas 46 ), p. 286)
Theme 4: Individual coping strategies for shopping and purchasing decisions
Coping strategies within the community nutrition environment
Sixteen articles from the USA, the UK and Mexico identified the resourcefulness of people in their use of food stores within the food environment to suit their needs and requirements. Thus consumers were seen to actively adapt to their local food environment( Reference Webber, Sobal and Dollahite 43 , Reference Cannuscio, Hillier and Karpyn 44 ). Such strategies included shopping at multiple stores or locations( Reference Webber, Sobal and Dollahite 43 , Reference Zenk, Odoms-Young and Dallas 46 , Reference Lindsay, Sussner and Greaney 57 , Reference Wiig and Smith 60 ) and also frequenting certain stores for specific purchases( Reference Webber, Sobal and Dollahite 43 , Reference Cannuscio, Hillier and Karpyn 44 , Reference Zenk, Odoms-Young and Dallas 46 ) due to both cost and preference considerations. For example, purchases made at corner stores were limited to just essential items because of their inflated prices( Reference Piacentini, Hibbert and Al-Dajani 41 , Reference Cannuscio, Hillier and Karpyn 44 , Reference Dammann and Smith 52 , Reference Tach and Amorim 54 , Reference Wiig and Smith 60 ). People also chose to shop at stores that were most convenient in undertaking their errands or fit with their routine( Reference Cannuscio, Hillier and Karpyn 44 ). Others prioritised shopping convenience over all other factors( Reference Webber, Sobal and Dollahite 43 , Reference Zachary, Palmer and Beckham 58 ) in an endeavour to frequent stores that were conveniently located( Reference Krukowski, McSweeney and Sparks 56 ), including shopping at the one location( Reference Webber, Sobal and Dollahite 43 , Reference Bridle-Fitzpatrick 55 ).
Coping strategies within the consumer nutrition environment
A number of individual approaches to food shopping and purchasing within food stores was discussed in twenty-four of the included articles from all study localities, with cost frequently referred to as the primary factor that dominated purchasing priorities, particularly for people of lower socio-economic status( Reference Yen, Scherzer and Cubbin 39 , Reference Piacentini, Hibbert and Al-Dajani 41 , Reference Munoz-Plaza, Filomena and Morland 42 ). People sought to minimise purchasing costs at the expense of all other purchasing considerations. Cost was deemed to be a more important consideration than the nutritional quality of foods( Reference James 36 ) and also dictated unhealthy food purchases regardless of people’s preferences for healthier items( Reference Zachary, Palmer and Beckham 58 ):
‘I know exactly what we should be eating and what would be healthy and all that and I’m really frustrated that we can’t eat that way … because there just ain’t enough money ...’ (Dammann and Smith( Reference Dammann and Smith 52 ), p. 246)
Cost was deemed a barrier to purchasing healthy items such as fruit and vegetables( Reference Inglis, Ball and Crawford 17 , Reference Lucan, Barg and Karasz 35 , Reference Lawrence, Skinner and Haslam 50 , Reference Krukowski, McSweeney and Sparks 56 , Reference Zachary, Palmer and Beckham 58 , Reference Baruth, Sharpe and Parra-Medina 61 ) in the USA, the UK and Australia, with healthy foods perceived as being more expensive( Reference Munoz-Plaza, Filomena and Morland 42 ) and unhealthy items seen as more cost-effective alternatives( Reference Zachary, Palmer and Beckham 58 , Reference Baruth, Sharpe and Parra-Medina 61 ). However, others found it more cost effective to buy fresh and seasonal foods rather than pre-packaged and pre-made items( Reference Dwyer, Needham and Simpson 59 ) or thought it was possible to eat healthily( Reference Whelan, Wrigley and Warm 51 ) if junk food purchases were reduced( Reference Withall, Jago and Cross 38 , Reference Dammann and Smith 52 ).
Regardless of study locality, articles discussed an array of in-store purchasing behaviours that people, predominantly of lower socio-economic status, applied to minimise the cost of their shopping. Techniques included searching for items on sale( Reference Webber, Sobal and Dollahite 43 , Reference Clifton 49 , Reference Whelan, Wrigley and Warm 51 , Reference Tach and Amorim 54 , Reference Lindsay, Sussner and Greaney 57 , Reference Zachary, Palmer and Beckham 58 ); buying items in bulk( Reference Clifton 49 , Reference Tach and Amorim 54 , Reference Wiig and Smith 60 ); comparing prices( Reference Piacentini, Hibbert and Al-Dajani 41 , Reference Zachary, Palmer and Beckham 58 ); buying store brands( Reference Whelan, Wrigley and Warm 51 , Reference Tach and Amorim 54 ); settling for cheaper cuts of meat( Reference Whelan, Wrigley and Warm 51 , Reference Wiig and Smith 60 ); trying to get the best value for money( Reference Piacentini, Hibbert and Al-Dajani 41 , Reference Zachary, Palmer and Beckham 58 , Reference Baruth, Sharpe and Parra-Medina 61 ); and refusing to buy certain items if they were considered too expensive( Reference Webber, Sobal and Dollahite 43 ).
Consumers discussed the importance of ensuring an adequate quantity of food for their family rather than quality food within their budget constraints( Reference Whelan, Wrigley and Warm 51 , Reference Dammann and Smith 52 , Reference Krukowski, McSweeney and Sparks 56 , Reference Zachary, Palmer and Beckham 58 ). One article from the UK also discussed various in-store shopping styles routinely applied within the store environment, including ‘restricted and budgeted’ shoppers, characterised by very controlled and planned purchases, often within the confines of price considerations( Reference Thompson, Cummins and Brown 62 ).
For those of higher socio-economic status from US, Australian and Mexican populations, cost rarely drove purchasing decisions( Reference Yen, Scherzer and Cubbin 39 ), which were instead prioritised by taste and food quality preferences, the convenience of accessing foods as well as the health benefits of their food choices( Reference Inglis, Ball and Crawford 17 , Reference Bridle-Fitzpatrick 55 ).
Discussion
The current review sought to synthesise qualitative evidence regarding the influence of the local food environment on food and purchasing behaviours. Availability, accessibility and affordability were consistently identified as key determinants of store choice and purchasing behaviours that often resulted in less healthy food choices within community nutrition environments. Food availability and quality within stores, and food store characteristics within consumer nutrition environments, also greatly influenced in-store purchases. Media and advertising as well as other environmental characteristics each influenced food purchasing behaviours. People used a range of individual coping strategies in both the community and consumer nutrition environments to make optimal purchasing decisions, often within the context of financial constraints.
Findings also identified distinct differences in themes that emerged from the articles depending on whether they were based within US populations or elsewhere. It appeared that the key themes of affordability (within the community nutrition environment) and in-store food quality and food store characteristics or features (within the consumer nutrition environment) were more often discussed in articles from the USA. In addition to this, race-based factors were discussed solely in US-based articles. This potentially highlights between-country variations and thus contextual differences between food and social environments( Reference Macintyre 63 , Reference Cummins and Macintyre 64 ). For example, while evidence tends to suggest the presence of cost and access disparities for low-income and minority communities in the USA, this is not necessarily consistent in other countries such as the UK( Reference Cummins and Macintyre 64 , Reference Cummins 65 ). Differences in the actual food environments and people’s use of these between countries can make research undertaken in different contexts difficult to compare( Reference Lake and Townshend 1 , Reference Cummins and Macintyre 64 ).
All but three articles had a specific focus on or discussed socio-economic factors both at the community or individual level and their influence on food acquisition. It was not surprising therefore that cost of food was continually identified as the most important influence. This finding reinforces the importance of socio-economic status and its contribution to disparities in food access, availability and cost, and is generally supported within the available literature( Reference Walker, Keane and Burke 66 – Reference Morland, Wing and Diez Roux 68 ).
Quality assessment outcomes of included articles were concerning for aspects of research design and reporting but were not formally used to separate study results. Poorer-quality articles were included, given their novelty and potential to still provide a rich and insightful contribution to the findings generated from the review. Regardless, there is a need to ensure high-quality and rigorous processes and reporting while undertaking future qualitative research endeavours.
Although the current review was focused on the role of environmental determinants on food behaviours, the synthesis identified challenges in seeking to explore environmental factors in isolation from other social-ecological determinants of behaviour. Indeed, consideration of the inequalities and challenges experienced by lower socio-economic and minority populations in accessing and making purchasing decisions within the food environment was key to consolidating findings across studies. Food and purchasing decisions are influenced by more than just the environment and thus the importance of intra- and interpersonal, social and cultural factors that influence behaviour must not be underestimated( Reference Richard, Gauvin and Raine 69 ). Policy and behavioural change interventions should still embrace a socio-ecological approach beyond exploration of the environmental determinants presented in the current review( Reference Sallis and Glanz 70 ).
Synthesis also highlighted distinct individual approaches to food shopping and purchasing within the community and consumer nutrition environments, primarily due to socio-economic (financial) constraints. These approaches demonstrate the dynamic interplay between structural barriers that exist within the environment and the capacity of human agency when faced with limited community, social and financial resources( Reference Rose 48 ), which cannot be overlooked in terms of the influence of solely environment on food behaviours( Reference Kremers, de Bruijn and Visscher 71 ). An individual’s agency is also underpinned by his/her motivation, ability and opportunity in undertaking certain behaviours( Reference Brug 72 ), as seen by the array of coping mechanisms applied and demonstrated through people’s resourcefulness and adaptation to their food environments to meet their purchasing requirements. However agency is limited, particularly if structural constraints are too difficult to overcome( Reference Rose 48 ).
The current review is not without its limitations. The systematic search process included empirical literature published in peer-reviewed journals and thus did not incorporate grey literature, government reports or forthcoming research, potentially missing other important contributions in the field. Furthermore, the scope of the review was limited to including only community and consumer food environments and therefore excluded research in organisational environments including schools, childcare centres, workplaces and the home environment due to the additional breadth and diversity of outcomes that would result from their inclusion. A vast majority of the included articles (n 19) were from research undertaken in the USA and given the variability within these food environments and also compared with other countries, this could impact the applicability of findings and result in an inability to make generalisations to different populations. Finally, the review did not incorporate synthesised results regarding food security issues and the use of food assistance programmes; although mentioned in a number of articles (n 9), it was deemed this topic could not be adequately addressed within the chosen scope of the review, given its breath, scope and complexity.
To our knowledge, the current systematic review is the first to synthesise qualitative research on the local food environment and food consumption and purchasing behaviours. The findings from this synthesis will assist in providing a deeper and more comprehensive understanding of environmental determinants within community and consumer nutrition environments that are consistent with findings from quantitative research in the field( Reference Cummins and Macintyre 64 , Reference Walker, Keane and Burke 66 ). Moreover, they may help to explain the inconsistent quantitative associations found between the food environment and dietary behaviours by emphasising the complexity and diversity of contextual factors that exist within these environments.
Future research should focus on integrating findings from qualitative and quantitative food environment syntheses in order to generate both new and refined hypotheses for ongoing research into the associations between aspects of the food environment and health/diet-related behaviours. Given the significant focus of included articles on socio-economic determinants, future research could explore how different people use the same food environment; that is, what characteristics result in individuals using food environments in different ways. This synthesis provides a summation of qualitative literature that could be used to guide policy formation and continue to develop tailored and multicomponent interventions within food environment research.
Conclusion
Environmental factors continue to be identified as pertinent determinants of food store selection and purchasing behaviour. Regardless of an individual’s ability to cope with less than optimal environments through the power of human agency, the environment needs to be modified and improved in order to maximise health-related outcomes. There is a need to investigate contextual influences within food environments as well as individual and household socio-economic characteristics that contribute to the differing use of and views towards local food environments. Greater emphasis on how individual and environmental factors interact in the food environment field will be key to developing stronger understanding of how environments can support and promote healthier food choices.
Acknowledgements
Financial support: E.P. was supported by a Griffith University Postgraduate Research Scheme scholarship. C.C. was supported by a Public Health Fellowship (grant number ID428254) from the National Health and Medical Research Council (NHMRC) Australia. This research did not receive any specific non-financial support. Conflict of interest: None. Authorship: E.P. conducted all searches, data extraction, quality appraisal, synthesis of results and writing the manuscript. D.G. and L.T. contributed to the synthesis of results. All authors contributed to the conceptual design of the research, editing and approval of the final manuscript prior to submission. Ethics of human subject participation: Ethical approval was not required for this paper as articles included in this systematic review and the findings generated were from existing studies available in the public domain.
Supplementary material
To view supplementary material for this article, please visit http://dx.doi.org/10.1017/S1368980017001069
